New ER systems may cut care to inner cities

Alex Bloom

As hospital systems expand, many feel the need to expand their services into new facilities. But a new trend of establishing satellite emergency care facilities may be creating a separate and unequal health care system.

Satellite emergency systems are being established in places like Washington, D.C.’s INOVA Health System and Kansas City’s HCA Midwest Health System. These facilities are designed to alleviate crowded emergency rooms and handle less intensive emergencies.

“The hospital determines that there are opportunities for broader range of services and more immediate access to services but short of needing a whole new hospital facility,” said Jane Arnold, a partner in the health care practice group of Bryan Cave LLP in Missouri. Arnold has helped several hospitals develop satellite emergency rooms.

These facilities are fully integrated in the parent hospital with serious cases requiring specialists going to the parent hospital.

“An ambulance would know not to take someone seriously in need of immediate care to one of these satellite emergency rooms,” said Arnold.

However, it is the idea that these facilities will make it easier and more convenient for suburban residents to receive care and resources, rather than traveling into inner cities, that is casting these facilities as potentially discriminatory.

“Part of it is that they don’t want to travel as far or go to a confusing [facility],” said Arnold. “Most of these larger hospitals are in urban cores.”

A high percentage of patients who enter emergency rooms in urban centers are minorities and have a higher chance of being uninsured. Hospitals lose money when they treat uninsured patients.

“To the extent that the hospital owner is expanding services, they’re more likely to expand services into an insured population rather than expand services to hit an uninsured population,” said Arnold.

Dr. Steven Thomas of the Center for Minority Health at the University of Pittsburgh is appalled at the thought of resources being diverted out of urban centers.

“Who would have imagined that we would have vestiges of racial discrimination in our health care system?” said Thomas. “We’re seeing market justice over social justice.”

Deborah Stone, the Research Professor of Government and Public Policy at Dartmouth University, noted that hospitals are able to bypass civil rights legislation, such as Title VI of the Civil Rights Act, with “business necessity defense.”

In 1980 in the case of Bryan v. Koch, a Second Circuit court ruling allowed the closing of Sydenham Hospital in Harlem due to business necessity, removing care for many of the areas minority residents. The closing, according to Stone, was essentially economic discrimination.

“We have to do this,” said Stone, detailing the rationale of hospital systems using this defense. “This is the only way to stay alive as a business.”

Both Thomas and Stone agreed that hospitals need to keep serving all populations regardless of whether the care goes to a paying suburbanite or an uninsured minority.

“The fact that [the system] is broken in general doesn’t mean the burden should fall on those who are disadvantaged and poor,” said Thomas. “Our system is broken for everybody and those who live in the wealthiest areas, they do not benefit from people who are left behind. We all lose.”

Since the satellite facilities are tied to the parent hospital, Arnold believes that resources will not be diverted out of inner cities.

“To the extent that it’s a revenue generator, that money should go back into the urban core facility,” said Arnold. “The main hospital has to be at least as well or better staffed because the patients rely on the main hospital for all specialty care.”

“If the model works, and it’s a relatively new model, it should bolster the strength of the urban facility without creating a whole new hospital, which would lead to diverting resources.”

Urban hospitals are not the only hospitals establishing these facilities, as satellite emergency centers are being used in rural Texas, rural Nevada and southern New Jersey. Arnold said that hospital systems are utilizing these satellite facilities for patient convenience rather than market profits.

“They can see where their patients are coming from and they want to assure that that population is served as efficiently as possible,” said Arnold.

These facilities have yet to emerge in Massachusetts, according to Gerald Ryan of the Massachusetts Hospitals Association.

“Hospitals have been providing quality care across the state of Massachusetts for a great number of years,” said Ryan. “Massachusetts residents have come to rely on them, trust those hospitals that are there in the communities, particularly Boston.”

Ryan admitted, however, that such facilities could come to the region.

“I don’t like to predict the future, but I know there have been attempts to establish facilities similar to satellite emergency rooms,” said Ryan.

Paul Biddinger, the director of operations for the Department of Emergency Medicine at Massachusetts General Hospital, has not seen any evidence of satellite care facilities, but compared the facilities to urgent care centers. Those facilities handle the same problems as satellite emergency facilities, but without many of the amenities of a full-fledged hospital.

“Most of them can take care of basic medical complaints like a cough, fever, urinary tract infection or simple lacerations,” said Biddinger. “They certainly can’t take care of very sick or very complicated patients.”

Urgent care centers are capable of serving minorities better, largely because they are located in the neighborhoods where minorities live. The centers can also better interpretive services. Additionally, since some of them are affiliated with local medical practitioners, patient records are more readily available and wait times are shorter.

Biddinger also noted that these urgent care facilities are not subject to the Emergency Medical Treatment and Active Labor Act, passed in 1986. The legislation guaranteed that all patients must receive a medical screening examination without consideration of their insurance status. The reason these facilities are exempt is that they do not open 24 hours a day like a hospital and they do not have to have access to basic specialists such as general surgery and internal medicine.

Arnold believes that satellite facilities help patients since they cater to patient wishes for convenience, rather than promote discrimination.

“It’s really governed by maximizing the convenience of the patients rather than pandering to their fears,” said Arnold.

Satellite facilities still operate under controversy though since they use market needs to determine facility placement.

“I think there are limits,” said Thomas of market governance in society. “When it comes to health lifesaving, I do not think we should be less vulnerable to the whims of the market.”